Notable transmitted HIV drug resistance among people who inject drugs in Pakistan

Transmission of drug-resistant HIV strains to treatment-naïve patients can compromise antiretroviral therapy (ART) effectiveness and lead to treatment failure. In Pakistan, transmitted HIV drug resistance among people who inject drugs (PWID) is fuelled by a lack of ART, poor drug adherence, and unsafe injection practices, resulting in efficient transmission in large injecting networks. A cross-sectional study was conducted among PWID recruited in the Pakistani cities of Karachi, Larkana, Peshawar, Quetta and Hyderabad (August 2014 to January 2015). A portion of the HIV pol gene was amplified from HIV-reactive dried blood spot specimens ( n =282/367) and sequenced using an in-house Sanger sequencing assay for HIV drug resistance mutation genotyping. Drug resistance mutations (DRMs) were identified using the Stanford University HIV Drug Resistance Database HIVdb algorithm (). Overall, HIV subtype A1 was dominant (78.0%; n =220), followed by CRF02\_AG (15.6%; n =44), CRF35\_AD (2.5% n =7), recombinants (3.5%; n =10), and subtype C (0.4% n =1). DRM analysis identified over half (63.8%) of participants harbored at least one DRM, of which 28.9% reported using help from a professional injector. Nearly all (99.4%) participants were not actively receiving ART because most (88.7%) had never undergone HIV testing and were unaware of their status. Findings suggest significant transmitted HIV drug resistance present among PWID, exacerbated by unsafe injection practices, particularly professional injection. Low testing rates signal a need for more comprehensive testing programs to improve HIV status awareness and ART coverage in Pakistan. Given most treatment-naïve participants had evidence of drug resistance, drug resistance genotyping prior to ART initiation might aid in ensuring effective treatment to prevent transmission of resistant HIV strains. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics board approval was obtained from the Health Research Ethics Board at the University of Manitoba [HS15691(H2012:294)] and BRIDGE Consultants Foundation, Pakistan. Informed consent was obtained verbally from study participants and documented by a member of the data collection team for the behavioural survey and biological sampling components of this study. Verbal consent was chosen due to varying levels of literacy among study participants and as an additional measure of protecting their identities. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study have been deposited in a public repository (i.e. NCBI) under accession numbers [MN887780][1]-[MN888069][2]. [1]: /lookup/external-ref?link_type=GEN&access_num=MN887780&atom=%2Fmedrxiv%2Fearly%2F2024%2F05%2F02%2F2024.04.30.24306644.atom [2]: /lookup/external-ref?link_type=GEN&access_num=MN888069&atom=%2Fmedrxiv%2Fearly%2F2024%2F05%2F02%2F2024.04.30.24306644.atom